Latest articles and more
Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19
At the beginning of the COVID-19 Public Health Emergency (PHE), CMS used emergency waiver authorities and various regulatory authorities to enable flexibilities so providers could rapidly respond to people impacted by COVID-19. CMS has developed a cross-cutting initiative to use a comprehensive, streamlined approach to reestablish certain health and safety standards and other financial and program requirements at the eventual end of the COVID-19 public health emergency.
This CMS cross-cutting initiative aims to evaluate CMS-issued PHE blanket waivers and flexibilities to prepare the health care system for operation after the PHE. This review is being done in three concurrent phases:
- CMS is assessing the need for continuing certain blanket waivers based on the current phase of the PHE. Since the beginning of the PHE, CMS has both added and terminated flexibilities and waivers as needed. In doing so, CMS considered the impacts on communities — including underserved communities — and the potential barriers and opportunities that the flexibilities may address.
- CMS is assessing which flexibilities would be most useful in a future PHE, such as natural and man-made disasters and other emergencies, to ensure a rapid response to future emergencies, both locally and nationally, or to address the unique needs of communities that may experience barriers to accessing health care.
- CMS is continuing to collaborate with federal partners and the health care industry to ensure that the health care system is holistically prepared for addressing future emergencies.
As CMS identifies barriers and opportunities for improvement, the needs of each person and community served will be considered and assessed with a health equity lens to ensure our analysis, stakeholder engagement, and policy decisions account for health equity impacts on members of underserved communities and health care professionals disproportionately serving these communities.
- The Interim Final Rule and waivers can be found at: Current emergencies | CMS
Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System Final Rule (CMS 1765-F)
On July 29, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System (SNF PPS) for fiscal year (FY) 2023. In addition, the final rule includes updates for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY 2023 and future years. CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for nursing homes on an annual basis. This fact sheet discusses the major provisions of the final rule.
FY 2023 Updates to the SNF Payment Rates
CMS estimates that the aggregate impact of the payment policies in this final rule would result in an increase of 2.7%, or approximately $904 million, in Medicare Part A payments to SNFs in FY 2023 compared to FY 2022. This estimate reflects a $1.7 billion increase resulting from the 5.1% update to the payment rates, which is based on a 3.9% SNF market basket increase plus a 1.5 percentage point market basket forecast error adjustment and less a 0.3 percentage point productivity adjustment (as required by law), as well as a negative 2.3% (or $780 million decrease) in the FY 2023 SNF PPS rates as a result of the recalibrated parity adjustment, which is being phased in over two years. These impact figures do not incorporate the SNF VBP reductions for certain SNFs. These reductions are estimated to be $186 million in FY 2023.
On June 29, 2022, CMS sent a memo to the State Survey Agency Directors providing revisions, clarifications and new guidance on the Requirements of Participation (RoP) that is effective October 24, 2022.
The revised guidance includes changes to the following:
F600, F607, F608, F609, F610 – all related to the freedom from abuse, neglect and misappropriation;
F622 related to admission, transfer and discharge;
F812 related to food and nutrition;
F689. F740 and F741 – related to mental health and substance use disorder (SUD);
F725 – related to nursing service staffing and specifically sufficient staff;
F61, F557, F563 and F582 – all related to resident rights;
F641, F658, F659 and F758 – related to comprehensive person-centered care plans and potential inaccurate diagnosis and/or assessment;
F755 and F757 related to pharmacy;
F880, F881 and F882 – related to infection control;
F847, F848 and F851 – related to administration;
F940, F941, F944, F945, F946 and F949 – related to training practices including infection prevention training and ethics training;
F910 and F919 related to physical environment;
F699 related to quality of care;
F865, F867, F687, F687, F687 and F868 related to QAPI with multiple additional requirements; and
State Operations Manual Chapter 5 have all been revised, updated or additional material has been added.
Please see details at: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/revised-long-term-care-surveyor-guidance-revisions-surveyor-guidance-phases-2-3-arbitration
The COVID-19 Public Health Emergency (PHE) was extended for another ninety (90) days on Friday, July 15, 2022. The PHE was initially declared on January 27, 2020 and has been renewed continuously since then. The extension of the PHE declaration was made partially because of the recent increase in COVID-19 cases and hospitalizations in the country, as well as in Pennsylvania. Some waivers that were initially implemented with the start of the PHE declaration have been or soon will be terminated. Please check the CMS website for a list of terminated or winding waivers. The waiver for the three day qualifying stay waiver does remain in place.
The Centers for Disease Control (CDC) on Tuesday July 12 released updated guidance on enhanced barrier precautions (EBP) in nursing homes related to the threat of multidrug-resistant organisms (MDRO). The guidance expands the use of gowns and gloves during high-contact resident care activities. Nursing home residents are at high risk for MDRO colonization which places them at high risk for serious illness. The use of EBP should now extend to any resident with an indwelling medical device or wound, regardless of MDRO colonization or infection status. The CDC cautioned that the new guidance does not replace existing recommendations for contact precautions. More information can be found on the CDC website at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html.
Prevalence high in LTC
Nursing home residents have a high prevalence of MDRO colonization, putting them at risk for becoming seriously ill, according to CDC data. In fact, one large study across nursing homes found that almost 6 in 10 residents in facilities that are not ventilator capable were colonized with an MDRO. In ventilator-capable nursing homes, which care for the most complex residents, that proportion rose to 76%, or nearly 80 in 100 residents colonized with these organisms, according to Kara Jacobs Slifka, M.D., MPH.
Most of these colonizations remain undetected, Slifka, a medical officer with the CDC’s Infection Prevention and Control Response Team, said in a Wednesday nursing home stakeholder call. But transmission of these bugs, which can occur during patient care, contributes to “substantial resident morbidity and mortality” in nursing facilities, the CDC stated in an updated webpage at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
Apply EBP broadly
The new implementation guidance addresses this risk by expanding the range of residents for whom EBP use applies. EBP is no longer limited to outbreaks or specific MDROs and should be applied more broadly, Slifka said.
Along with residents who have an infection or colonization with an MDRO, the use of EBP should now extend to any resident with an indwelling medical device or wound, the new guidance stated. For these residents, EBP should be used no matter their MDRO colonization or infection status, and in most situations, EBP should be continued throughout the duration of the resident’s stay. The CDC also expanded the types of MDROs it includes in its EBP recommendations. Details on specific organisms can be found on the updated webpage. The new guidance does not replace existing recommendations on the use of contact precautions for other pathogens in nursing homes such as Clostridioides difficile and norovirus, the agency added.
Getting it right
Staff training and ready supplies are critical to getting these precautions right, the CDC further noted. The updated guidance includes practical suggestions for encouraging awareness of the facility’s expectations and increasing on-the-ground availability of supplies.
“Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care,” the CDC stated.
The new guidance can be found on the CDC’s website at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
The Centers for Medicare & Medicaid Services has held audiences with skilled nursing providers, made presentations and entertained comments in recent months to assure operators that regulatory actions are being done with best intentions.
But there’s one area that remains a particularly sore spot with nursing home operators, and that point was re-emphasized at the recent NADONA annual meeting in New Orleans.
State surveyors do not have to be vaccinated against COVID-19 to enter any nursing home, the CMS nursing home division chief told dismayed nurse leaders during a live video address last week.
“I can’t go into much of the details. It basically came down to our authority of what we can and can’t do,” said Evan Shulman, director of CMS’ nursing home division, to heads shaking in disappointment. “I understand where you’re coming from, but at the end of the day, this is the direction we had to go in. For you all, you need to let the surveyors in.”
Providers have been incredulous that while the U.S. Supreme Court upheld a CMS requirement that healthcare workers either be vaccinated or receive a waiver, surveyors are under no such obligation. Worse, they could visit multiple facilities in a given week, acting as unknowing, asymptomatic spreaders, as occurred in the very first US outbreaks in Seattle-area long-term care facilities in 2020.
“If you have any concerns about [surveyors], about, for example, wearing PPE, just reach out to the state survey agency,” Shulman advised. “But it’s the direction we need to go in.”
In addition, providers may not require surveyors to be tested for COVID before entering a building, he added. CMS in mid-June rescinded guidance that said surveyors who aren’t fully vaccinated shouldn’t be part of the onsite survey team when inspecting certified providers.
“No, you need to let the surveyor in,” he explained to rising murmurs of dissatisfaction. “If you have concerns, reach out to your state survey agency. You can ask [surveyors to test] but you cannot block them.”
Leaders at LeadingAge received similar responses after inquiring with CMS.
“Providers may inquire about the vaccination status of a surveyor, may offer testing to the surveyor, and may request the surveyor to wear [PPE] such as a respirator for source control,” Jodi Eyigor, LeadingAge’s director of nursing home quality and policy, wrote in a blog post late last week. “Note, however, that the surveyor may refuse these provisions including refusing to disclose vaccination status, refusing testing, or refusing PPE such as a respirator, and other extra precautions.”
Federal data as of mid-June shows 87% of nursing home staff have completed their primary vaccination series, while 87.6% of residents have done the same.
In his NADONA address, Shulman addressed numerous topics that would be more fully and formally introduced in final guidance about the Phase 3 Requirements of Participation that was released the next day.
Another of the touchier topics was the concern some providers have about being able to get temporary nurse aides properly tested by CMS’s Oct. 6 deadline. The agency took away a pandemic-induced aide-training waiver earlier this spring.
“This is a very, very delicate balance, folks, I’m going to be completely candid,” Shulman acknowledged during his long-distance address. “On one hand, we do not want to create barriers for facilities to retain staff. On the other hand, we are seeing significant issues related to staff not being trained and certified. We want to be very careful about how we proceed here. We’re going to try to thread that needle the best we can.”
PADONA’s 34th Annual Convention will be held Tuesday, March 29 through Friday, April 1, 2022. We are looking for dynamic speakers who are interested in sharing their knowledge and expertise with our membership and convention attendees. Our live conference brings 400+ nurse leaders and nursing home administrators together for 4 days at The Hotel Hershey. 85% of our attendees are Registered Nurses serving in roles such as Director of Nursing, Assistant Director of Nursing, Corporate Nurse, Staff Development, Infection Preventionist, MDS Coordinator, and Nurse Managers. 45% of our attendees are licensed Nursing Home Administrators. Requested / Suggested topics are included in the Call for Speaker form.
Proposals for educational content can be submitted via the attached proposal form and will be accepted through December 17, 2021. Please contact Candace McMullen at firstname.lastname@example.org with questions.
We hope to see you in Hershey this spring! PADONA Call for Speakers 2022 Convention
The attached article, published in the American Journal of Infection Control was co-authored by Sharon Bradley, Senior Infection Prevention and Patient Safety Analyst/Consultant, of the Pennsylvania Patient Safety Authority. Many of you will recognize Sharon as one of our convention presenters. The article has been provided with her permission. Identifying safe practices urinary leg bag systems in LTC.
Pursuant to the PADONA Bylaws, the Board’s duties include reporting, annually, to the members, the business transacted throughout the year. The Board offers the following report of our business transactions as completed in calendar year 2018. Please contact Candace McMullen, Board Chair, with any questions. PADONA Annual Report 2018
CMS has made additional changes to items on the PDPM webpage. This is a resource for providers as we prepare for implementation of the new Medicare reimbursement system. The updates were completed by CMS on April 4. Not all items on the webpage were updated. We encourage you to check the valuable resources on the CMS webpage and the recent updates.
The annual PEPPER report for SNF’s will be released on or about 4/5/19. To access your facility’s PEPPER data, you need to log on to the TMF website below. Select the appropriate portal based on your CMS Provider Number.
The Centers for Medicare & Medicaid Services (CMS) recently released a full listing of 2567 Statement of Deficiencies information compiled through November 2018. This provides a full year of data from state surveys conducted under the revised survey process that is based on the regulations that became effective November 28, 2017. It is noteworthy that three of the top ten most cited deficiencies are #5 – F755 Pharmacy Services, #6 – F761 Labeling and Storage of Drugs and Biologicals, and #10 – F758 Psychotropic Medications. The #1 most cited F-Tag is F880 – Infection Control, which can have significant connection to medication administration practices.
PADONA recommends continuing the close relationship that you have with your pharmacy services provider and consultant pharmacist. Communicate this CMS information and work together to be proactive in preventing these deficiencies in your facility.
Attached are forms that are required to be completed and given to the State Agency during recertification surveys. They are being posted in a format that can be saved and provided to the survey team upon entrance.
Please note the Entrance Conference Worksheet for NHA is being provided in addition to a State Entrance Conference Checklist and a SNF Beneficiary Protection Notification form.
Please note the Matrix with Instructions.pdf (CMS-802 (11/2018)) must be used instead of earlier versions.
On January 10, 2019, a training teleconference titled “Updates for a Rapidly Changing MDS World” was presented. To receive a compact disc (CD) of this teleconference, please complete and fax the attached form to Myers and Stauffer at 717-541-1206. The associated handouts will be included on the CD.
Whether you are interested in becoming a member, exhibitor, sponsor, scholarship recipient, etc, we will answer all of your questions. Lets schedule your free consultation.